Greenhurst Nursing Center

Based on observation, record review, and interview, it was determined that the facility did not ensure medications were stored securely while the medication cart was left unattended, for two (Hall 100 and Hall 200) of four medication carts. The findings include: During an observation of medication administration on 07/23/2025 at 9:07 AM, Licensed Practical Nurse (LPN) #1 left the medication cart unattended and proceeded up the hall from the 200-hall dining room to the medication storage room at the front of the facility, out of the sight of this surveyor. The medications left unattended on top of the cart included partial blister packs each of a beta-blocker used to treat high blood pressure, an alpha-blocker used to treat high blood pressure, a diuretic used to treat fluid retention, an anti-diabetic medication, a mineral supplement used to lower potassium levels, and a steroid. There was also one partial bottle each of chewable aspirin, a multi-vitamin with minerals, and a probiotic supplement. At 9:12 AM, LPN #1 returned to the medication cart and confirmed all the medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure an Advanced Beneficiary Notice (ABN) was provided within two business days and notification of their financial liability for care and services after the Medicare coverage was discontinued for one (Resident #4) of three residents reviewed for ABN notices. The findings include: A review of Resident #4’s admission Record indicated the facility admitted the resident on 03/21/2025, with diagnoses which included vascular dementia with mild anxiety, stroke, prostate cancer, bone cancer, and personal history of transient ischemic attack. A review of Resident #4's quarterly Minimum Data Set with an Assessment Reference Date of 04/30/2024, revealed a Brief Interview for Mental Status score of 08, which indicated the resident had moderately impaired cognition. A review of Resident #4’s Care Plan, with a revision date of 03/27/2025, revealed the resident had a stroke. The resident’s Care Plan indicated a goal for Resident #4 to show improvement to maximum potential to perform activities of daily living. A review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide mandatory staffing payroll data in a uniform format to CMS (Center for Medicare and Medicaid Services). The findings include: 1. The data that CMS received from the facility did not include the CASPER (Certification and Survey Provider Enhanced Reporting) PBJ (Payroll Based Journal) mandatory staffing data. According to policy, the failure to not submit the mandatory data within the date range specified to the facility by CMS, constitutes a citation. a. According to CMS regulations, long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. b. The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following: The category of work for each person on direct care staff (including, but not limited to, whether the individual is a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles/practices to prevent administration of medicines that had been opened and stored beyond the manufacturer's specified timeframes, and the administration of expired medications in 1 of 1 medication rooms and 2 of 4 medication carts. The findings are: On 04/15/2024 at 11: 30 AM, in Medication Storage room [ROOM NUMBER] the first upper cabinet had 13 Covid tests that all shared the same expiration date of 11/10/2023. The second upper cabinet contained 1 tube of a nonsteroidal anti-inflammatory cream with an expiration date of 06/2019 and 1 bottle of eye drops that expired 03/2022. On 04/15/2024 at 11:41 AM, the Assistant Director of Nursing (ADON) was asked what nurses do with expired prescription medications. The ADON reported the nurses will bring them to this locked medication storage room. The information, such as name of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure staff performed hand hygiene to prevent the contamination of clean laundry/linens and further prevent the potential spread of infection. The findings are: Review of a facility policy titled, Infection Control, not dated, specified, [Facility] establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Procedure: Infection control is managed not only through basic hygiene but managed through the QA [Quality Assurance] Committee, for review of infection control tracking and trends; quarterly . Clean Linens and Clothing: Resident should have clean linens to prevent any infections. Linens should be changed and cleaned when dirty or soiled. Clothing should always be clean and look neat . Hands should be washed before handling clean linens . Clean linens and clothing should not be shaken or placed in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to provide specialized respiratory care in accordance with professional standards of practice for 1 (Resident #66) of 5 (#16, #39, #50, #66, #245) sampled Residents who had a Physician's Order for nebulizer treatments as documented on a list provided by the Director of Nursing on 03/16/23 at 9:55 a.m. The findings are: 1.Resident #66 had a diagnosis of Acute Respiratory Failure with Hypoxia. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/23 documented a score of 15 (11-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. On 03/13/23 at 11:15 a.m., Resident #66 was sitting in a recliner beside the bed. A nebulizer machine with tubing and mask were lying on the bed. The tubing and mask were not stored in a bag. b. On 03/13/23 at 01:10 p.m., Resident #66 was sitting in a recliner beside the bed. A nebulizer machine with tubing and mask were lying on the bed. The tubing and mask were not stored in a bag. The Surveyor asked, Who put that mask on your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure medications were stored and labeled properly for 1 (Resident #38) sampled Resident on the 100 Hall, and the facility failed to ensure a medication was not left unattended on top of the 200 Hall medication cart. This failed practice had the potential to affect 58 residents who resided on the 100 and 200 Halls, as documented on the Midnight Census Report provided by the Administrator on 03/13/23 at 11:54 AM. The Findings are: 1. Resident (R) #38 had a diagnosis of Fracture Right Radius and Ulna. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/23 documented a score of 15 (11-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. The Care Plan on 03/15/23 at 1:11 PM dated 01/06/23, .desires to administer own medication when dispensed by the nurse . will maintain medicine cup and take within time frame for administration once nurse has dispensed . b. The Physician's Order on 03/15/23 at 1:12 PM, dated 01/16/23 documented, Throat Lozenges…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to accurately record the Minimum Data Set (MDS) assessment for 2 Residents #89, #94 of 22 (#1, #4, #6, #7, #11, #14, #16, #19, #27, #34, #38, #39, #45, #50, #66, #75, #77, #78, #88, #89, #93, #94) sampled Residents whose MDS was reviewed. The findings are: 1.Resident (R) #89 was admitted to the facility on [DATE]with diagnoses of Psychotic Disturbance, Mood Disturbance, and Anxiety Disorder. A Quarterly with an Assessment Reference Date (ARD) of 12/24/22 documented R #89 was severely impaired in cognitive skills for daily decision making on a Staff Assessment of Mental Status (SAMS). Wandering behavior not exhibited documented in section E. Pressure alarms were not documented in section P of the MDS. a. A Record Review Progress Notes dated 11/28/22 at 11:21 documented, .Incident Note Text: Clarification of recent incident report. Resident did not trip over stool. As she was ambulating across the room unassisted her alarm box that was hanging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to refer 1 (Resident #88) sampled resident who was identified with a newly evident or possibly serious mental illness or intellectual disability to the appropriate state-designated authority for Level II PASARR evaluation and determination. This failed practice had the potential to affect 13 residents in the facility who had a diagnosis of serious mental illness or intellectual disability as documented on a list provided by the Administrator on 03/16/23 at 8:00 AM. The findings are: 1. Resident #88 had a diagnosis of Psychotic Disorder with Delusions Due to Known Psychological Condition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 documented a score of 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). a. The Physician's Order dated 12/09/22 documented, Seroquel Tablet 25 MG [milligrams], Quetiapine Fumarate Give 0.5 tablet by mouth at bedtime related to other psychotic disorder not due to a substance or known physiological condition - d/c…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure proper placement of gastrostomy tube was checked prior to water flush and medication administration based on professional standards of care for 1 (Resident #79) of 2 (#1, #79) sampled Residents reviewed with Physician Orders for gastrostomy tube feedings. This failed practice had the potential to affect 3 residents according to a list provided by the Administrator on 03/16/23 at 8:00 AM. 1.Resident #79 was admitted to the facility on [DATE] with Diagnoses of Dysphagia following Cerebral Infarction, Disorders of Eustachian Tube, and Encounter for Attention to Gastrostomy. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/22 documented Resident #79 was severely impaired in cognitive skills for daily decision making on a Staff Assessment for Mental Stats (SAMS) and required total one-person physical assistance for eating. Section K documented a Feeding tube. a. The Care Plan dated 06/10/21 documented,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.